Building toilets in rural India, where hundreds of millions are still defecating outdoors, will not be enough to improve public health, according to a study published Friday.
India is considered to have the world's worst sanitation record despite spending some $3 billion since 1986 on sanitation programs, according to government figures. The country is now gearing up to spend 10 times that amount, as new Prime Minister Narendra Modi makes garbage and sanitation troubles a key issue for his first year in office.
However, the new study—published Friday in the Lancet medical journal—suggests India needs to look beyond building toilet infrastructure and focus also on educating the masses and changing centuries-old habits and people's preferences for doing their business outdoors.
For the study, Indian and U.S. researchers looked into the effects of a 2011 government sanitation campaign in 100 villages in the eastern state of Orissa.
They found almost no improvement in childhood rates of diarrhea, parasitic worm infections and other public health scourges that experts say contribute to childhood stunting, malnutrition and some $54 billion in lost productivity each year, according to the World Bank.
The program was "effective in building latrines, but not all households participate," lead author Prof. Thomas Clasen of Emory University in Atlanta said in a statement. Poor hygiene practices, water contamination and unsafe disposal of baby poop also likely contributed to the problem, he said, though the researchers said more work was needed to understand the complex problem and how to fix it.
Experts note that many of the 640 million Indians still defecating in the open might opt not to use a toilet, even if they had one at home, thanks to widespread preferences for going outside.
Another unrelated study looking at attitudes toward sanitation in five Indian states—Bihar, Haryana, Madhya Pradesh, Rajasthan and Uttar Pradesh—found that 40 percent of homes that had toilets also had at least one household member who openly defecated. Most said that was because it was "pleasurable, comfortable and convenient," according to the paper titled "Revealed Preference for Open Defecation," published last month in Economic and Political Weekly.
"Many respondents told us that defecating in the open provides them an opportunity to take a morning walk, see their fields, and take in the fresh air," the paper's authors wrote. "Many people regard open defecation as part of a wholesome, healthy, virtuous life."
While the attitudes may be somewhat of a symptom of reality in those states—which together account for almost half of all toilet-free households in India—they show that "latrine construction is not enough to substantially reduce open defecation in the northern plains states."
Few understand there is a connection between their outdoor ablutions and the fact that, each year, hundreds of thousands in India die from diarrheal diseases.
William Easterly, an economics professor at New York University who specializes in development issues, also cautioned against the danger in seeing a single object, in this case a toilet, as a magical solution to solve a public health concern. "A few years ago, it was bed nets for malaria."
"Victories in sanitation and clean water in the U.S. and many other places were achieved by democratically accountable local and national health officials. There is no way to technologically bypass these political requirements," said Easterly, who was not involved with the study.
The Lancet study "shows a common failing of top-down programs in development," he said. "A more bottom-up approach would seek to learn much more about local context and keep searching for solutions, which may differ from one context to another, anywhere in the complex web of interactions between human behavior and pathogens."
Journal information: The Lancet
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